Immediate jeopardy has been fully removed at Ascension St. Thomas Hospital in Nashville, Tenn., following a Sept. 4 revisit survey, according to a Sept. 16 letter obtained by Becker’s. But a 99-page Statement of Deficiencies shows the hospital remains out of compliance on several fronts, and a possible Medicare termination looms ahead.
CMS had originally threatened to terminate the hospital’s Medicare agreement Sept. 18, but extended the deadline to reach substantial compliance to June 16, 2027 — giving the hospital roughly nine additional months to fix what surveyors found.
Immediate jeopardy was originally identified during an Aug. 16-21 survey across three areas of hospital operations: governing body, pharmaceutical services and surgical services. That survey followed an Aug. 14 medication error in which four surgical patients were injected with potassium phosphate instead of the intended anesthetic, mepivacaine, an event the hospital confirmed had harmed four patients and that CEO Shubhada Jagasia, MD, said was self-reported to state regulators the day it occurred.
The Aug. 21 exit survey left all three immediate jeopardy citations in place after the hospital’s first three removal plans were rejected as unacceptable. CMS followed with an Aug. 26 letter warning that immediate jeopardy had to be resolved by Sept. 18 or the hospital’s Medicare provider agreement could be terminated, and Ascension St. Thomas Midtown and St. Thomas West both faced losing their Medicare status as a result, since Midtown operates as a satellite facility of West under CMS’ system.
The Sept. 2-4 revisit survey found immediate jeopardy had been removed for pharmaceutical services and surgical services. Immediate jeopardy for governing body followed Sept. 10 after the hospital submitted additional documentation. That clears the hospital’s most severe, emergency-level noncompliance designation across all three conditions where it was cited.
Lifting immediate jeopardy is not the same as coming into compliance, though. The Statement of Deficiencies found the hospital’s governing body still failed to oversee contracted services, follow serious adverse events through to resolution, and ensure pharmaceutical services were safe.
The anesthesiologist involved in the Aug. 14 error was never restricted from clinical duties while it was under investigation and remained on the schedule afterward. The hospital’s quality assessment and performance improvement program also failed to properly track, investigate or disseminate lessons from 22 of 22 adverse-event records reviewed, including two previously unreported incidents: an Aug. 12 pharmacy compounding and mislabeling near-miss, and an Aug. 20 event in which a medication was administered without being scanned. Surveyors further found no established protocol for treating intrathecal medication errors, contributing to a roughly seven-hour delay before spinal lavage treatment began for the harmed patients.
The hospital submitted five separate immediate jeopardy removal plans between Aug. 18 and Sept. 2 before regulators accepted the corrective actions. Its deemed status remains revoked, and it stays under Tennessee State Survey Agency oversight rather than its usual accreditation pathway.
In a Sept. 16 statement, Ascension said it has engaged an independent quality consultant to verify its corrective actions and that its hospitals “remain open, operational, eligible for Medicare, and fully committed to serving the Middle Tennessee community.”
